Nationwide survey on the current practice of ventricular tachycardia ablation.

METHODS: We performed a nationwide survey on the current practice of ventricular tachycardia catheter ablation in Italy during the year 2016. RESULTS: Among 145 operators participating in the survey, 58 (40.0%) did not perform any ventricular tachycardia ablation in 2016. Among those performing ventricular tachycardia ablation, 9 operators (6.2%) performed only right ventricular endocardial catheter ablation, 52 (35.9%) performed endocardial catheter ablation both in the right and left ventricle (LV) and 26 (17.9%) performed both endocardial and epicardial LV catheter ablations. Seventy operators (89.7%) among the 78 performing LV and epicardial ablations treated patients with ischemic cardiomyopathy; ablations in the setting of other causes were less frequently performed. The following were considered as minimum requirements for ventricular tachycardia ablation: presence of a three-dimensional mapping system (120 operators, 82.8%), ICU in the hospital (118 operators, 81.4%), operator's training in high volume centers (93 operators, 64.1%). Twenty-eight operators (19.3%) performed catheter ablation in patients with electrical storm only after hemodynamic stabilization, 41 operators (28.3%) also during the acute phase and 9 operators (6.2%) never performed catheter ablation in electrical storm patients; the remaining 67 operators did not perform ventricular tachycardia ablation at all, or performed ablations only in the right ventricle. CONCLUSION: The present survey provides a snapshot of the current invasive treatment of ventricular tachycardia by catheter ablation. The procedure, especially in the setting of ischemic cardiomyopathy, is performed nationwide. Complex cases, including those with electrical storm, should be managed within a preestablished integrated network of regional referral centers able to transfer patients as soon as possible.

Impact of continuous intracardiac ST-segment monitoring on mid-term outcomes of ICD-implanted patients with coronary artery disease. Early results of a prospective comparison with conventional ICD outcomes.

BACKGROUND: Although myocardial ischaemia monitored by some implantable cardioverter-defibrillators (ICDs) might improve patient care, the clinical usefulness of this technology has not yet been validated. OBJECTIVE: To investigate the potential impact of ICD-based ischaemia monitoring on clinical care and patient management of ICD recipients. DESIGN: Prospective, controlled, non-randomised study. SETTING: Single-centre, university hospital. PATIENTS: Consecutive patients with known coronary artery disease, followed up for at least 6 months. INTERVENTIONS: Patients implanted with either an ICD providing continuous intracardiac ST monitoring (n=53; ST group) or with an ICD without this capability (n=50). MAIN OUTCOME MEASURES: Major cardiovascular events, appropriateness of ST-shift episodes and unscheduled device-related visits. RESULTS: During follow-up (15.4±8.4 months), one patient experienced ST-shift events confirmed by angiography to be related to myocardial ischaemia. Myocardial infarction was a rare event and occurred in one patient (ST group) who had an ST-elevation myocardial infarction 3 weeks after the implant, but at this time the algorithm had not yet been activated. In the ST group, seven patients had one or more episodes of false-positive ST events (median 9, range 1-90). The programmable features of the device helped overcome the problem in six patients. Among patients with a remote monitoring system, unscheduled outpatient visits were significantly increased in the ST group (17 vs 4; p=0.032). CONCLUSIONS: Although, this study was underpowered by the small number of acute ischaemic events, ICD-based ST monitoring failed to provide a benefit over ICDs without this capability and increased unscheduled evaluations in patients with remote follow-up. The sensitivity and specificity of the algorithm still require validation.

n-3 polyunsaturated fatty acids for the prevention of arrhythmia recurrence after electrical cardioversion of chronic persistent atrial fibrillation: a randomized, double-blind, multicentre study.

AIMS: Persistent atrial fibrillation (AF) often recurs after direct current electrical cardioversion (ECV). As several experimental and clinical studies suggest that n-3 polyunsaturated fatty acids (PUFAs) may have antiarrhythmic properties even at the atrial level, we aimed to evaluate whether oral supplementation with PUFAs, in addition to conventional antiarrhythmic drugs, could reduce the recurrence rate of the arrhythmia after ECV of persistent AF. METHODS AND RESULTS: Two hundred and four patients (mean age 69.3 years, 33% females) with persistent AF were randomly assigned to receive 3 g/day of PUFAs until ECV and 2 g/day thereafter (104 patients) or placebo (100 patients) for 6 months, beginning at least 1 week before ECV. Selection of conventional antiarrhythmic prophylaxis was left to local medical advice. The cardiac rhythm was assessed by both trans-telephonic monitoring and clinical visits. Primary end-point was the recurrence rate of AF. Sinus rhythm was restored, either spontaneously or after ECV, in 187 patients (91.7%); 95 patients (91.4%) on PUFAs and 92 patients (92.0%) on placebo (P=not significant). AF relapsed in 56 (58.9%) of the PUFAs patients and in 47 (51.1%) of the placebo patients (P=0.28). The mean time to AF recurrence was 83±8 days in the PUFAs group and 106±9 days in the placebo group (P=0.29). CONCLUSION: Our results do not support the hypothesis that, in patients undergoing ECV of chronic persistent AF, supplementation with PUFAs in addition to the usual antiarrhythmic treatment reduces recurrent AF.

Impact of pre-existent areas of complex fractionated atrial electrograms on outcome after pulmonary vein isolation.

BACKGROUND: Atrial fibrillation (AF) drivers outside pulmonary veins (PV) may account for failure after PV isolation. The aim of this study was to characterize pre-existent areas of complex fractionated atrial electrograms (CFAEs) recorded in right atrium (RA) and in coronary sinus (CS) during catheter-based PV isolation and to assess their relation to outcome. METHODS AND RESULTS: With a tricuspid annulus and CS mapping, CFAEs were retrospectively identified in consecutive patients who underwent PV isolation. Of 224 patients, 161 were found to have CFAEs (81%). No clinical variable was found to be predictive of CFAEs presence. By Kaplan-Meier analysis, following a median follow-up of 23.7 months after a single ablation procedure, 62.8% of patients in the CFAEs+ group and 85.4% of those in the CFAEs- group were free from recurrent atrial tachyarrhythmias (p=0.013). Multivariable Cox regression analysis showed that CFAEs evidence was an independent predictor of recurrence (p=0.007). CONCLUSIONS: Pre-existent CFAEs, that can be easily identified in RA and CS during PV isolation, are a powerful independent predictor for AF recurrence. This finding may be helpful for refining AF ablation strategies.

In vitro activity of levofloxacin against recent Gram-negative nosocomial pathogens.

The objective of our study was to evaluate the in vitro activity of levofloxacin in comparison with other antibiotics (coamoxiclav, ceftriaxone, ceftazidime, meropenem, aztreonam, ciprofloxacin and netilmicin) against about 500 Gram-negative nosocomial microorganisms, isolated during 2003. The bactericidal activities (minimal bactericidal activity and killing curve) of levofloxacin and the other antibiotics were also evaluated. The results confirm the excellent in vitro activity of levofloxacin against multiresistant nosocomial Gram-negative pathogens, including the 73 extended spectrum beta-lactamase producer strains (90% of Escherichia coli, Enterobacter cloacae and Klebsiella pneumoniae were inhibited at 0.5 mg/l). Of particular interest is its susceptibility and bactericidal activity against Stenotrophomonas maltophilia strains. In conclusion, due to the favorable pharmacokinetics and pharmacodynamics of the molecule, associated with its safety, levofloxacin may represent a valid therapeutic option in the treatment of severe Gram-negative nosocomial infections.

Transesophageal low-energy cardioversion of atrial fibrillation without fluoroscopy outside the electrophysiology laboratory.

BACKGROUND: Low-energy internal cardioversion (LEIC) is a safe and effective procedure for the restoration of sinus rhythm in patients with atrial fibrillation refractory to external cardioversion. However, the procedure needs fluoroscopy and the use of the electrophysiology laboratory, even when the esophageal approach is utilized. The aim of this study was to assess the efficacy, safety and tolerability of a new simplified procedure of esophageal LEIC performed without fluoroscopy, outside the electrophysiology laboratory. METHODS: Thirty consecutive patients (23 males, 7 females) with persistent atrial fibrillation were submitted to LEIC using a step-up protocol (by steps of 50 V, starting from 200 V). Twenty (66%) were resistant to external cardioversion. A large surface area lead (cathode) was positioned within the esophagus, 45 cm from the nasal orifice. A second large surface area lead (anode) was positioned in the right atrium via the right internal jugular vein without fluoroscopic control. Synchronization of delivery of the shock with the QRS was achieved by means of two cutaneous electrodes positioned on the thoracic wall. RESULTS: Sinus rhythm was restored in 28 patients (93%) with a mean delivered energy of 15.2 +/- 7.5 J (range 5-27 J) and a mean impedance of 48.3 +/- 5.6 Ohm. No complication occurred during and after the procedure that was well tolerated under sedation. CONCLUSIONS: This new technique of performing esophageal LEIC is effective and seems to be safe and well tolerated. In this way internal cardioversion can be performed without fluoroscopy, outside the electrophysiology laboratory.